Provider Demographics
NPI:1811482102
Name:HAIDATOV, KRISTINA (OD)
Entity type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:
Last Name:HAIDATOV
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21519 73RD AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-2928
Mailing Address - Country:US
Mailing Address - Phone:718-819-8477
Mailing Address - Fax:718-819-8534
Practice Address - Street 1:21519 73RD AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11364-2928
Practice Address - Country:US
Practice Address - Phone:718-819-8477
Practice Address - Fax:718-819-8534
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008824152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist